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Date Archives: 20-Dec-2013

Question: A nitro virgin patient presenting with chest pain attends a doctor's office. Doctor administers 1 spray of nitro prior to EMS arrival. Upon assessment by EMS, patient still presents with chest pain. Is the patient still considered a virgin nitro patient as this is the first incident he/she has had with nitro? Or since the doctor administered a spray, does that count as a previous use of nitro?

Answer: The SWORBHP teaching philosophy regarding NTG and ischemic chest pain has always been previous prescribed use. Meaning, the patient at one point had been advised by a health care professional to take NTG for this suspected ischemic discomfort, and the patient had in fact done so without complication.

In the scenario you describe above, you have a patient who has had NTG administered by a physician for chest pain of a presumed ischemic etiology and this was done without complication. As such, the SWORBHP Medical Council would consider this as previous prescribed use and as such would be supportive of the paramedic administering subsequent dosages of NTG as per the medical directive.

Question: If you come to a scenario being a PCP paramedic uncertified in IV, where when finding and assessing the patient you come to terms that he/she is VSA due to anaphylaxis. Do you have to administer epi, because in the protocol for administering epi on a VSA, it says "in the event anaphylaxis is suspected as the causative event of the cardiac arrest, a single dose of 0.01mg/kg 1:1000 solution, to a maximum of 0.5mg IM, may be give prior to obtaining the IV/IO". Since it is saying you "may" give it, do you know if you have a choice?

Answer: The PCP Medical Cardiac Arrest Medical Directive states that paramedics are to consider epinephrine (only if anaphylaxis suspected as causative agent) in the dosing you have described above.

The wording however “may be given prior to obtaining the IV/IO” is taken from the ACP Medical Directive and is not present on the PCP Medical Directive. As such, the issue of a PCP waiting for the IV/IO is irrelevant.

As an aside, the conventions of the Medical Directives state, the word “consider” is used repeatedly throughout the medical directives. Where this word appears, it indicates that a paramedic should initiate the treatment unless there is strong clinical rationale to withhold it.

Question: Multi-part question on croup. I've heard that croup is becoming more prevalent in older children (8 years & up). What is the incidence of croup in older children, and how would their treatment differ in the ER from the < 8 year old group?

Answer: Thanks for the question. Although the OBHG ALS companion guide makes reference to croup occurring in older children and adults and the existence of a few case reports in the literature of croup occurring in adults, this is a VERY rare occurrence and one you will unlikely encounter.

In children greater than 6 years, the etiology of stridor is more likely to be caused by something other than croup. According to UpToDate: Croup most commonly occurs in children 6 to 36 months of age. It is seen in younger infants (as young as three months) and in preschool children, but it is rare beyond age six years. It is more common in boys, with a male:female ratio of about 1.4:1.

References:

Woods, C.R.(2013). Clinical features, evaluation, and diagnosis of croup. In M.Torchia (Ed.), UpToDate. Available from http://www.uptodate.com

Question: I recently did a transfer with a physician going to LHSC University Hospital with a confirmed subarachnoid bleed. The patient was conscious, conversed and was oriented x 3. They were mildly lethargic, c/o an occipital headache with no neuro deficits. The physician accompanied the patient to give a medication to keep the BP on or around 140 systolic. During transport, the patients BP began to rise to 160-180 because of nausea and vomiting. Gravol was administered and a drug (sorry, I can't recall the name). He asked me if we carried anything that could drop the BP. He suggested Nitro. I know this is not listed as a contraindication but would it be wise to give a vaso dilator to a patient with a cerebral bleed. We did not administer nitro, but the question still remains. Thanks in advance.

Answer: Thanks for the question. Often in the setting of raised Intracranial Pressure (ICP), physicians attempt to maintain the Mean Arterial Pressure (MAP) to a certain level in order to maintain Cerebral Perfusion Pressure (CPP). As such, if required, to lower the MAP, physicians can select a wide variety of medications which have varying degrees of vasodilatation.

One of the concepts as well is if the MAP is lowered it may even lessen bleeding. Acting as a vasodilator (although we see the paradox) does not mean that the blood vessel itself will widen the opening that contributed to the hemorrhage initially and nor would this same property (vasodilatation) actually increase the ICP.

Question: We are instructed to get the nitro in, if applicable, apply the CPAP and if there is improvement, do not remove the mask for additional nitro sprays. Is the improvement slight or significant? If slight improvement, do we leave the pressure at the slight improvement pressure or titrate 2.5cmH2O?

Answer: You are absolutely correct. If it is felt that acute pulmonary edema is the likely cause for a patient’s respiratory distress, then CPAP would be indicated along with Nitroglycerin (NTG) as per the Acute Pulmonary Edema Medical Directive.

Again you are correct that it has been our teaching at SWORBHP that if a patient with pulmonary edema is improving with CPAP, there is no need to keep removing the mask to administer NTG especially given the physical difficulty of administering a spray of NTG sublingually when high flow oxygen is also being applied.

To answer your question in terms of clinical improvement and how best to define it, as long as your patient is in respiratory distress (as evidenced by a paramedic clinical judgment and a significantly elevated respiratory rate, accessory muscle use etc.) and the oxygen saturation is < 92%, paramedics should titrate the CPAP pressure and FIO2 as per the Medical Directive.

Specifically, the Medical Directive calls for paramedics to consider increasing the FIO2 if the patient SAO2 is < 92% despite treatment and/or 10cmH2O pressure or equivalent flow rate of device as per BH direction.

The directive also lists the titration interval of 2.5cm H2O every 5min to a maximum setting of 15cm H2O and a maximum FIO2 of 100%.

Question: If respirations are at or above 28, historically paramedics are taught to assist via BVM. What is the rationale with pulmonary edema to apply NRB with tachypnea instead of assisting with a BVM until CPAP and or nitro is prepared?

Answer: The SWORBHP Medical Council does not entirely agree with the teaching that a patient with a respiratory rate at or above 28 requires assistance with ventilations using a BVM. Paramedic clinical judgment and other assessment factors should lead a paramedic to determine that the use of a BVM is required.

In the BLS Patient Care Standards, a patient who is short of breath should have ventilations assisted if breathing is deemed inadequate as evidenced by signs and symptoms of hypoxia (e.g. decreased LOC, cyanosis).

Basic Life Support Patient Care Standards- January 2007, Version 2.0, Section 2-Medical Patient Categories, page 46, Shortness of Breath, Breathing Difficulty in Adults and Children –Not Related to Trauma

Therefore to answer your specific question, if a paramedic based upon clinical judgment feels that a BVM is indicated to support a patient with respiratory distress and inadequate ventilations, then it is entirely appropriate to do so while preparing the CPAP. It is also acceptable to administer high concentration FIO2 via a NRB if the clinical judgment of the paramedic on scene if ventilations are assessed to be adequate.

Question: There is some debate in regards to chest compression's, monitor applied, analyze and then airway. What happens when the compression count is at thirty and the pads are still not applied? Does the paramedic at the chest check the oral cavity, get the airway, insert it, open the BVM bag, prepare the BVM and attempt 2 breaths or continue compression's until the other medic applies the pads and the analysis is complete?

Answer: The 2010 American Heart Association Guidelines (Berg et al Part 5: Adult Basic Life Support Circulation 2010) state the following in terms of initial rescuer sequence:

A change in the 2010 AHA Guidelines for CPR and ECC is to recommend the initiation of compressions before ventilations. While no published human or animal evidence demonstrates that starting CPR with 30 compressions rather than 2 ventilations leads to improved outcomes, it is clear that blood flow depends on chest compressions. Therefore, delays in, and interruptions of, chest compressions should be minimized throughout the entire resuscitation. Moreover, chest compressions can be started almost immediately, while positioning the head, achieving a seal for mouth-to-mouth rescue breathing, and getting a bag-mask apparatus for rescue breathing all take time. Beginning CPR with 30 compressions rather than 2 ventilations leads to a shorter delay to first compression (Class IIb, LOE C).

Once chest compressions have been started, a trained rescuer should deliver rescue breaths by mouth-to-mouth or bag-mask to provide oxygenation and ventilation, as follows:

Use a compression to ventilation ratio of 30 chest compressions to 2 ventilations.

The SWORBHP Medical Council advises that given the above, ventilations are required via a BVM after 30 compressions to achieve the recommended 30:2 compression ratio. You are absolutely correct that the priorities are good compressions and defibrillation. Paramedics should however work as a team on scene to apply the defibrillator as early as possible and ideally the defibrillator will be ready to analyze by the time the 30 compressions are complete.
However, to answer your specific question, if the defibrillator is not ready to analyze once the 30 compressions have been completed, interrupting compressions to provide 2 ventilations as per the recommended 30:2 ratio is acceptable.

Question: I was told by a physician that a DNR becomes void with a suicide attempt. I was wondering how we should approach this situation.

Answer: This is an interesting question and hopefully a rare clinical situation. Suicide specifically is not addressed in the MOHLTC Training Bulletin on the DNR Standard.

One of the first issues with this clinical scenario (DNR/Suicide patient) would have to be: who is it that activated 911? If there is a family member or other individuals who are present on scene demanding that CPR be initiated, then this is addressed by the MOHLTC training Bulleting on the DNR Standard.

In Section 1 A point #2 if the DNR Standard it states: A paramedic WILL initiate CPR on a patient who has experienced a respiratory or cardiorespiratory arrest when the substitute decision maker (SDM) has rescinded a valid DNR confirmation form by stating he/she wishes CPR to be performed or there is confusion as to who the SDM is and/or one or more people present at the time is demanding that CPR be initiated on the patient.

If there are no bystanders present on scene but somehow 911 was activated (perhaps by the patient themselves prior to self-harm) the other consideration would be to patch to the BHP for further direction in this rare situation.

Question: I was taught that if there is some clinical improvement, when using CPAP, we are not to titrate the pressure any higher. I understand the rationale for this, however my question is, are there clinical guidelines that quantify a patient having sufficient "clinical improvement"? Example being a patient breathing at a rate of 34 bpm with accessory muscle use, sp02 of 85%, audible crackles through all 4 lobes. With CPAP applied at 5 cmH20 vitals improve to RR of 28 bpm, sp02 of 91% and crackles remain. This patient has had a degree of improvement but would it not be advisable to titrate the pressure 2.5 cmH20 higher (after 5 mins) to attempt to further normalize the patient's VS and clinical condition? Or is the goal to increase the sp02 above 90 % with no accessory muscle use and decrease RR below 28 bpm as the directive lists these as conditions needed for application.

Answer: The Advanced Life Support Patient Care Standards Continuous Positive Airway Pressure (CPAP) Medical Directive actually does direct paramedics to increase/titrate the pressure and the FIO2.

The Medical Directive calls for paramedics to consider increasing the FIO2 if the patient SAO2 is < 92% despite treatment and/or 10cmH2O pressure or equivalent flow rate of device as per BH direction.

The directive also lists the titration interval of 2.5cm H2O every 5min to a maximum setting of 15cm H2O and a maximum FIO2 of 100%.

Therefore to answer your specific question, as long as your patient is in respiratory distress (as evidenced by a paramedic clinical judgment and a significantly elevated respiratory rate, accessory muscle use etc..) and the oxygen saturation is < 92%, paramedics should titrate the CPAP pressure and FIO2 as per the Medical Directive.